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illinois chiropractic society

Forms and templates library

Editable forms and templates for your practice.

Do You Need that Perfect Form for Your Practice?

The following forms are researched, flexible, accurate, and easily tailored to your practice needs. ICS members in good standing can download, edit, and continue to utilize these forms and templates for FREE in their offices throughout their membership lives (please see licensing terms and conditions below). Downloading is an easy one-step process – When you select to download a form below, we will take you to your account and automatically download the form.

Click on the form name or the + to expand the category listing. Once expanded, you will find a link to the various forms and templates along with a link to an article that explains how to use the linked form. Jump to your needed category by clicking a category button here:

Consent

Financial

HIPAA

Human Resources

Insurance

Other

Patient Resources

Scope

Good Faith Estimates

Insurance

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Assignment and Designation of Authorized Representative

 

Template Assignment and Designation of Authorized Representative Explanation

 

ERISA Letters and Requests
Form Assignment and Designation of Authorized Representative Explanation
Template Letter of Appeal Post Service Claim - Lack of Medical Necessity Insufficient information Provided by Plan to Respond Explanation
Template Request for Summary Plan Description Explanation
Template Request for Summary Plan Description Explanation
Template Request to legal department or request to forward to legal Explanation
Template Letter of Appeal Post Service Claim - Lack of Medical Necessity Sufficient Information Provided by Plan to Appeal Explanation
Template Letter of Appeal Post Service Claim - Plan Exclusion Request for Summary Plan Description Only Explanation
Template Letter of Appeal Pre-Service Claim - Lack of Medical Necessity Insufficient information Provided by Plan to Respond Explanation
Template Request for Summary Plan Description Explanation
Template Request to Legal Department or Request to Forward to Legal Explanation
Resource Important Definitions and Resources Explanation

MEDICARE ADVANCED BENEFICIARY NOTICE

 

Form Advance Beneficiary Notice of Noncoverage ABN - English Explanation
Form Advance Beneficiary Notice of Noncoverage ABN - English Large Print Explanation
Form Advance Beneficiary Notice of Noncoverage ABN - Spanish Explanation
Resource Form Instructions Advance Beneficiary Notice of Noncoverage Explanation

NOTIFICATION OF NONCOVERED SERVICE
Form Notice of Non-Coverage Under Private Insurance or Health Plan Example
Template Patient Consent Form for Non-Covered Services - UHC and Medicare Advantage Template Explanation

PATIENTS’ RIGHT TO DIRECT PROVIDER NOT TO SUBMIT A CLAIM TO HEALTH PLAN
Template Request to Restrict Use or Disclosure (Release) of Example

NON-DISCRIMINATION APPEAL LETTER
Template Section 2706 Template Letter Explanation

ICD-10 Resources
Resource ICD-10 Quick Reference Guide Explanation

Consent

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Authorized Relative Certification
Template Authorized Relative Certification Explanation
Authorization, Consent and Release Template for Patient Photos and Videos
Template Authorization, Consent and Release Template for Patient Photos and Videos Explanation
INFORMED CONSENT AND PATIENT NON-COMPLIANCE
Template Informed Consent Form Explanation
Template Informed Consent Form (Spanish) Explanation
Template Consent to Chiropractic Examination and Care Explanation

Financial

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FINANCIAL HARDSHIP WAIVERS
Template Financial Hardship Waivers Explanation
FINANCIAL POLICY
Form Notice of Non Coverage Form Explanation
Template Financial Policy Template Explanation
HEALTH CARE LIENS
Template Notice of Health Care Professional Lien Explanation
SUBPOENAS TO TESTIFY
Template Petition for Fees Explanation
NON-DISCRIMINATION APPEAL LETTER
Template Section 2706 Template Letter Explanation
CALCULATING PROFITABILITY FOR PRACTICE SUCCESS
Resource Overhead Worksheet Sample Explanation

Scope

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ADVERTISING “PHYSICAL THERAPY
Resource IDFPR Letter: Use of Term “Physical Therapy" Explanation
MODIFYING STUDENT PHYSICAL EDUCATION
Resource School PE Letter Explanation
SCOPE/AUTHORITY TO ORDER
Template ICS Member Scope of Practice Authority to Order Physical Therapy Form Letter Explanation
Template Generic Scope of Practice Form Letter Explanation
Chiropractic Physician Authority to Perform Occupational Therapy
Template Chiropractic Physician Authority to Perform Occupational Therapy Explanation

Patient Resources

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AN OPIOID EPIDEMIC TOOLBOX
Resource A Natural Solution to the Opioid Crisis Explanation
CHIROPRACTIC HEALTH CARE MONTH: RESOURCES
Resource Chiropractic Saves Explanation
Resource What Does A Full Life Look Like Explanation
Resource Chiropractic Health Care Month: Social Media Library Explanation
DRUGS OR CHIROPRACTIC CARE FOR LOW BACK PAIN?
Resource Low Back Pain Flyer Explanation
Patient Insurance Informational Flyers
Resource Why Are Copays So High - Flyer These materials are for patient education and advocacy only and may not be modified or used for commercial purposes.
Resource How Insurance Models Impact Care - Flyer These materials are for patient education and advocacy only and may not be modified or used for commercial purposes.
Resource Don't Let Prior Authorization Delay Your Care - Flyer These materials are for patient education and advocacy only and may not be modified or used for commercial purposes.
Resource When Your Care Gets Manipulated These materials are for patient education and advocacy only and may not be modified or used for commercial purposes.

HIPAA

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HIPAA BREACH NOTIFICATIONS
Template HIPAA Breach Notification Explanation
Template HIPAA Breach Media Notification Explanation
HIPAA COMPLIANCE
Form Patient Consent Form Explanation
Form Business Associate Agreement Explanation
Form Patient Authorization Explanation
Template Privacy Policy Explanation
Template HIPAA Physical Control Maintenance Records Log Explanation
HIPAA Right of Access
Form HIPAA Right of Access Request Explanation
Form HIPAA Right of Access Request PDF Explanation

Human Resources

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EMPLOYEE CONCEALED CARRY
Template Workplace Weapons Ban Policy Explanation
PPACA REQUIRED NOTICE
Form New Health Insurance Marketplace Coverage Options and Your Health Coverage Explanation
Mandated Reporter
Form Acknowledgment of Mandated Reporter Status Explanation
Notice to Consult with Attorney Re: Covenant Not to Compete or Covenant Not to Solicit
Template Notice to Employee Restrictive Covenant Explanation
Notice and Authorization for Employee Credit Check
Form Notice and Authorization for Employee Credit Check Explanation

Good Faith Estimates

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Good Faith Estimates
Template Good Faith Estimate Language for Website Explanation
Form Patient Good Faith Estimate Form Explanation
Template Right to Receive A Good Faith Estimate Explanation

Other

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CME TRACKING
Form Continuing Medical Education Category I (60 Hours Minimum) Explanation
Form Continuing Medical Education Category II (90 Hours Minimum) Explanation
CORONAVIRUS (COVID-19) IN THE CHIROPRACTIC PHYSICIAN OFFICE
Resource Updated Face Covering Poster Explanation
Form Telehealth Consent Form Explanation
Form Covid Screening Document - for patients Explanation
Form Covid Screening Document- For Staff Explanation
Template COVID-19 Template Letter for Patients of Chiropractic Physicians Explanation
Template COVID-19 Template Letter for Patients of Chiropractic Physicians in Spanish Explanation
Template Layoff Letter Template Explanation
Template Closing Notice Pandemic Template Explanation
Template Sample FFCRA Exclusion Notice Explanation
Resource Covid Face Covering Requirement Explanation
Resource Covid-19 Stop Sign Explanation
Resource Covid-19 Infection Control Policy Explanation
Office of Inspector General (OIG)
Template OIG Compliance Manual Explanation
OSHA
Template Bloodborne Pathogens Policy Explanation
Selling or Closing A Practice
Form Master Checklist for Selling or Closing a Practice Explanation

The Illinois Chiropractic Society (ICS) grants exclusively to ICS members in good standing (“authorized users”) a non-transferable license to use ICS Forms and Templates above for the purposes set out in the full terms and conditions. Your use of our site and its Forms and Templates constitute your agreement to abide by the Terms of Use and License of ICS Forms and Templates.

As a reminder, this License terminates for any Illinois Chiropractic Society member user at such time as the member is no longer in good standing according to the ICS bylaws. Users who are not in good standing, including without limitation those who are not current in payment of dues, are not authorized to use ICS forms and Templates, and any such use is strictly prohibited.